1. Module 6: Case Report Form (Chart Abstraction)

2. This training session contains information regarding:
Overview the CRF

3. At this point you have done the following:
Identified Eligible Respondents
Obtained Consent
Enrolled Respondents
Administered the ACP Questionnaire
Next… you will need to collect data from the medical record into the Case Report Form Completion (i.e. Chart Abstraction)

4. Identifying Respondents
In order for the site to be able to access the relevant medical record, they will need to know the unique, hospital assigned, medical record number. We recommend keeping an identification list. You can find a template on the study website.

5. What is a CRF? Data abstracted from medical charts
Official clinical data collection document
Data abstracted from medical charts
Allows for efficient and complete data processing, analysis and reporting
Study questions determine what data should be collected on the CRF

6. Tips for Completing Chart Abstraction
Understand what data you are looking for
Orient yourself to the various sections of your local medical charts
Paper
Electronic
Determine any local standards used to document ACP/AD
Sometimes there are several sources for the same information. The best thing to do is be consistent.

7. Documentation of ACP/AD in Medical Chart
The purpose of this section is to record any ACP/AD documents found on the medical record at the time the questionnaire is completed.
If both the patient and family member participate, section 5 should be completed at the point of first contact.
(i.e. after the first questionnaire is completed).

8. If blank documents are found in the medical chart (e. g
If blank documents are found in the medical chart (e.g. goals of care form, tracking record or My Voice workbook) leave the corresponding row blank.

9. Comorbidities Patient characteristics that affect outcomes
Medical Chart sources of info:
Admission notes, ED assessments, previous admission notes
Progress notes
Discharge Summary
Collect only those that appear on the CRF, record them by:
Body system
Illness/condition

10. Entering Data into REDCap
Once you have:
Administered the ACP questionnaire(s)
Collected the CRF data
Degree of system implementation
Proceed to enter the data into REDCap.
See Module 7 for instructions.

11. Training Module 6 Complete